Applying Lean Principles to Identify Barriers to Hand Hygiene

Authors: Hand Hygiene Leadership Committee, University of Chicago Medicine

Background

An institutional goal, incorporated into the hospital Annual Operating Plan, was established to reach or exceed 75% hand hygiene compliance upon entering and exiting a patient room or area.

• A multidisciplinary Hand Hygiene Leadership Committee was established providing representation from various clinical, administrative, operational, and quality improvement disciplines

• UCM is testing ECM to measure hand hygiene, with the hopes that better data will help us to improve actual hand hygiene performance.

• Two pilot units were selected to testing an aggregate ECM system in the adult inpatient setting. The team is applying Lean Principles to attempt to improve hand hygiene on those units.

• Voice of the Customer interviews were conducted on the pilot units to identify current views around HH behavior, reported compliance of HH for that unit, and the ECM system (see right for summary of themes.)

• This data was then extracted and analyzed using an Affinity approach. A team of leaders and front line staff from the pilot unit used the affinitized data to assist with the identification of potential failure modes and root causes of poor hand hygiene compliance.

• The team brainstormed potential solutions to those opportunities and then evaluated those opportunities based on impact to goal and ease of implementation. This allowed the team to prioritize and create an improvement roadmap.

Aims

Project Design/Strategy

• Hand Hygiene (HH) is the single best way to prevent the spread of Healthcare Associated Infections (HAIs) and provides an ideal opportunity for application of lean principles to healthcare worker (HCW) behavior.

• Despite overwhelming evidence and knowledge around the importance of HH, Hand Hygiene compliance of healthcare workers in hospitals across the country hovers between 18% - 45%.

• Our institution identified similar trends of compliance with HH performance hovering around 30% upon entering and exiting a patient room on two pilot inpatient units after implementation of an aggregate Electronic Compliance Monitoring (ECM) system (GoJo Smartlink.)

Changes Made• A Hand Hygiene Toolkit was created as a resource for management and staff

including education on the importance of HH, institutional policies and expectations, barriers to measuring HH, and suggested approaches for implementation of HH improvement efforts into daily practices.

• Institutional policy for Hand Hygiene was simplified and disseminated throughout the institution via intranet and email from Senior Leadership.

• To better incorporate Hand Hygiene into daily practices and to integrate with institution-wide Lean approaches, a HH measure was added to the unit’s KPIs (Key Performance Indicators) on their MDI (Managing for Daily Improvement) board. The board was also moved from the nursing workroom to a unit hallway to allow for multidisciplinary engagement in HH efforts.

• Multidisciplinary huddles were created and expectations around attendance set by hospital leadership to ensure engagement of all disciplines around HH through huddles held at the MDI board. Hand Hygiene is also a recurring topic at weekly multidisciplinary rounds.

• A roadmap for designing improvement of hand hygiene compliance was created, setting monthly Just Do It events with representation from clinical, administrative, facility planning, environmental services, and ancillary support staff dedicated to implementation of agreed upon solutions. Events to date have focused on design of workflow to ensure successful hand hygiene compliance, including:

• Room set up for new patients• Environmental services workflows & ensuring that pumps are always

full• Placement of soap and sanitizer pumps• Documentation and use of workstations on wheels

• Future events will address:• Transporting patients (specifically when PT/OT exit & enter room with

the patient)• Supply storage and the need to leave a patient room to get supplies• Empty patient rooms• Interdisciplinary champions and methods for individualized feedback

Outcomes & Lessons Learned

• Multidisciplinary engagement has been successful as measured by participation of each discipline in the Just Do It events. We will also track attendance of each discipline at unit-based shift huddles.

• The first pilot unit has shown small improvement over the first few months and

• Hand Hygiene performance continues to be monitored with anticipated improvement as improvement initiatives are rolled-out.

Next Steps

The developed Road Map will be followed and executed over the upcoming year, with Just Do It events guiding the design and implementation of individual interventions. The Plan-Do-Study-Act approach will be used to assess individual improvement initiatives and to monitor the overall effect on Hand Hygiene performance throughout this year-long journey. As the pilot units learn from their tests of change, those learnings will be integrated into the Hand Hygiene Toolkit.

We would like to acknowledge the project teams from 8 South and 8 West including Denise Berry, Martina Buttilgero, Aurea Enriquez, Cheryl Esbrook, William Fowler, Nateisa Hawkins, Catherine Houda, Liz Martin, Sherwin Morgan, Mark Myren, Michael O’Connor, William Pharr, Abigail Poiner, Megan Stulberg, Anthony Stull, Elaine Tsiakopoulos, David Velasco.

Acknowledgements

South WestBoth Units Combined

Think current # is low/bad 7 11 18Other Staff (sum of MDs specifically and any other) 14 20 34

Other Staff - MDs 8 9 17

Other Staff (any other than me personally or my discipline) 6 11 17

Patient, family, visitors 10 13 23 Forget 3 2 5 Urgency 1 3 4 Not enough time 4 5 9 GoJo User Interface 1 1 Don't Understand GoJo 8 11 19 Don't believe #s (are right or accurate) 2 8 10 Believe the #s 6 13 19 Standards unclear 1 2 3 Dispenser/HH equipment Issues 7 3 10 But I'm not touching anything… 9 8 17 Washed on way out, don't need to again on way in 1 2 3 Empty Rooms 1 1 2 Other count against when it shouldn't 2 2 Reminders (including POC, signs, and verbal) 8 8 16 Education 5 12 17 Accountability 7 7 Make it a competition 3 3 Offer rewards 2 1 3 Provide data 5 7 12 Provide data by discipline 4 4

System counts against us when it

shouldn't (perception)

How to improve

Number of Responses Containing Theme

Larger Affinity Group

18Spectrum of

forget, no time, urgent/emergent

57It's not me, it's

you

Affinity Group

Affinity Summary

24

HH compliance rate is visible 24/7 on a screen on the unit, and is summarized and shared weekly at multidisciplinary rounds.

Team members complete a fishbone diagram to help understand “why are dispensers empty?”